What Is a Prehospital Resuscitative Thoracotomy?
Prehospital resuscitative thoracotomy is a life-saving intervention generally performed in the emergency department or elsewhere and is an important part of bringing a critically injured unconscious patient who presents with penetrating chest trauma and cardiac arrest back to life. An alternate term for prehospital resuscitative thoracotomy is emergency thoracotomy.
To have a reasonable chance of survival, a resuscitative thoracotomy must be performed rapidly. This is the main reason for performing the procedure in a prehospital setting. A fully trained team is required to perform this potentially critical emergency thoracotomy. The main aim of the procedure is to control hemorrhage, repair cardiac or pulmonary injuries, release cardiac compression due to the accumulation of fluid in the pericardial sac, perform open cardiac massage, and expose the descending thoracic aorta for cross-clamping.
What Are the Indications of a Prehospital Resuscitative Thoracotomy?
The prehospital resuscitative thoracotomy procedure has a high mortality rate mostly because of the critical condition of the patients on whom the procedure is performed. So the selection of patients should be done cautiously, or it can be fatal to the patient. In the ideal patient, the treatment can save a life and lead to a good recovery and functioning following fatal injuries. The indications for prehospital resuscitative thoracotomy include:
-
Patients presenting with penetrating cardiac trauma.
-
Patients with identified cardiac tamponade on the FAST exam.
-
Patients who are pulseless and received CPR (cardiopulmonary resuscitation) in less than 15 minutes after injury.
-
Blunt thoracic injury and loss of vital signs without other major injuries such as severe head injuries or injuries sustained from car accidents with steering wheel trauma to the chest.
-
Multiple blunt traumas.
What Is the Procedure for Prehospital Resuscitative Thoracotomy?
If there is an indication for prehospital resuscitative thoracotomy, the decision to undergo a thoracotomy should be taken very quickly. The patient should be immediately shifted to an area where healthcare professionals have 360 degrees of access to perform further procedures.
-
The patient should be positioned in a supine position. Healthcare professionals should wear sterile gloves, eye protection, and head torches. The main focus of the medical team is to conduct a rapid resuscitative thoracotomy. So simultaneously, other members of the emergency and trauma teams should perform intubation, ventilation, intravenous access, etc., without delaying resuscitative thoracotomy. Time should be well spent preparing the skin and surgically draping the patient for asepsis, but a rapid application of skin preparation will be appropriate.
-
The fourth intercostal space should be identified. It lies in the mid-axillary line, approximately level with the infra-mammary fold in women and the nipple in men. Using a scalpel and blunt forceps, a bilateral two-inch small incision of the chest wall called thoracostomy is done along the line of the 4th interspace. This incision should aim to get through all skin layers and chest wall and take the shape of a swallow.
-
The two small incisions are connected with a deep incision using a Tuff Cut Shears up to the breastbone. Two fingers should be inserted into a thoracostomy to hold the lung out of the way while cutting the pleura and intercostal muscles towards the sternum with heavy scissors. This should be performed on both the left and right sides, leaving the sternal bridge between the two anterolateral thoracotomies.
-
Then the sternum should be cut with heavy scissors. If scissors are impossible, then a Gigli saw can be used. It is used by passing the large clamp under the sternum, grasping one end of the Gigli saw with the clamp, and pulling back under the sternum. Cutting the sternum may take a little more than 2 or 3 pulls.
-
Before opening the chest up, the incision should be extended in the intercostal space posteriorly to the axillary line. This will help open the chest widely in a “clamshell” fashion for better exposure and better anatomy identification. One or two large, self-retaining retractors or rib spreaders will help widen the chest. If this instrument is unavailable, the incision can be held open by one or two gloved assistants. If exposure is still inadequate, the incisions must be extended posteriorly.
-
If required, suction can be used to clear the field of work for better visualization. After identifying the heart, it is checked to see if tamponade is present. If the pericardium looks tense, it indicates tamponade. The pericardium should be opened if tamponade is present to inspect the heart.
-
With the help of Spencer Wells artery forceps, the pericardium is lifted, a small vertical hole is cut, and the cut is extended vertically using scissors. This will minimize the risk of phrenic nerve damage, which runs through the walls of the pericardial sac. Check if blood clots are present, then inspect the heart for the site of bleeding. If a blood clot is present, remove it.
-
After performing all these procedures, the heart may fibrillate or beat spontaneously. If there is no improvement, the heart should be flicked with a finger. Even after all these procedures, a massage should be done if there is no improvement. The massage must be of optimal quality using a two-hand or one-hand technique. While massaging, the heart should be flat in its bed and not kinked. The IV (intravenous) access should have been established by other team members by this time.
-
By this time, IV access should have been established. If the heart is empty, its volume should be inflated. Still, if the myocardial activity is sluggish, 1 mg of intracardiac adrenaline should be given to the right ventricle and massaged until the myocardial activity is regained effectively. If the procedure is successful, the internal mammary arteries will bleed, which should be stopped using ligation (tying a ligature tightly around a blood vessel). If the procedure is successful the patient may regain consciousness, healthcare professionals should be prepared to provide immediate anesthesia.
Conclusion:
Prehospital resuscitative thoracotomy is an emergency procedure mainly performed in cardiac arrest in penetrating chest trauma. This procedure should be done rapidly before or in the period shortly after cardiac arrest. Survival rates after resuscitative thoracotomy depend on the selection of the cases. The survival rate is lower in patients with blunt trauma and extrathoracic penetrating trauma. If the procedure is performed on a penetrative trauma patient or a pulseless patient, and if the procedure is commenced within 10 minutes of cardiac arrest, then there is a reasonable chance of success.
